Drug Awareness Business Chamber

 DONATIONS:

Donations can be paid into our banking account directly:

Bank: Standard Bank Hartbeespoort Account Number:410037397
Account Type: Current Branch Code: 013445

Simply complete the form below, and someone from Reality Media will contact you TO CONFIRM YOUR ONLINE APPLICATION
 Debit Order / Stop Order

DETAILS OF THE PERSON JOINING THE "REALITY MEDIA BUSINESS CHAMBER":
 Title:       Initials: Surname:
CONTACT NUMBER (h) CODE / KODE nO: KONTAK NOMMER (h)
CONTACT NUMBER (w) CODE / KODE nO: KONTAK NOMMER (w)
CELLULAR NUMBER   SELL NOMMER
e-MAIL E-MAIL
ADDRESS ADRES

DETAILS OF THE BUSINESS TO BE LISTED IN OUR MEMBERSHIP DIRECTORY
Reality Media is a Section 21 Company (non-profit) You will never be under any obligation to honour your monthly commitment to us. This monthly debit order will enable us to address local problems regarding drugs and substance abuse. The amount of R135.00 is suggested only. You may enter any amount you feel comfortable with.

We need 250 business to join us in order to start running a meaningful business directory. The FIRST 250 companies to join our business chamber will have the title "Founder Sponsor Member" and will also receive a certificate to that effect.
Company Details: Please Complete Please mail your company logo or picture to:

chamber@smartswop.co.za and please include your company name and date joined.
Company Name:  
Industry
City
Suburb
Business description
Keywords people may use in searching for your products and/or services A Maximum of 15 words
membership TYPE: Own Amount
PLEASE CONTACT ME BY: PHONE: FAX: E-MAIL: E-MAIL:
:: PERSONAL DETAIL FOR AUTHORISED DEBIT ORDER
FULL NAME OF ACCOUNT HOLDER:
ADDRESS OF ACCOUNT HOLDER:
NAME OF BANK: BRANCH:
CODE: ACCOUNT NUMBER:

Account Type Cheque Credit Card Savings Transmission  
DATE OF 1ST PAYMENT: Today's DATE:

 

SIGNATURE:..................................

 IDENTITY NUMBER:

TELEPHONE NUMBERS: Work
Home
Cell
E-MAIL ADDRESS:
PLEASE AD ME TO YOUR E-MAIL LIST: Yes, Please:   No, Thank You:
SHOULD YOU WANT TO VOLUNTEER YOUR SERVICES TO THE ORGANISATION IN ANY MANNER, PLEASE INDICATE BELOW:

I hereby acknowledge that the party hereby authorised to effect drawing/s against my account may not cede or assign any of its rights to any third party without my prior consent and that I may not delegate any of my obligations in terms of this contract/authority to any third party without written consent of the authorised party

BY CLICKING THE SEND BUTTON, YOU AGREE TO THE TERMS AS SET OUT ABOVE

 
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